Child's Sex Child's Full Name REQUEST FORM An alert request may be filed with respect to an unmarried child under the age of 18. This request can be filed by concerned parents of U.S. citizen children, their appointed agents, or other persons having legal custody of the child. Complete one form for each child, and submit the completed request along with proper documents to Passport Services by e-mail, fax or mail. By signing this form you are affirming that your parental rights to this child havenot been terminated by court order. Please provide information about the child in order to make the alert system effective. Please print clearly or type the information. 1. Female Please provide the following information about yourself so that we can acknowledge your request, and alert youin the future. 2. Your Full Name Relationship to ChildShown Above Mailing Address NOTE: Home Phone 3. Since the Department will need to contact you, it is very important that you keep us informed in writing or by telephone of any changes to your contact information. Failure to notify this office of your correct address and phone number may result in passport issuance for your child without your knowledge. REQUEST FOR ENTRY INTO CHILDREN'S PASSPORT ISSUANCE ALERT PROGRAM U.S. Department of State DS-3077 02-2016 Page 1 of 2 *OMB APPROVAL NO. 1405-0169 EXPIRATION DATE: 08-31-2019ESTIMATED BURDEN: 30 Minutes* (Last, First, Middle) Date of Birth Place of Birth U.S. Passport Number , if any Documentation of Identity Provided Male Social Security Number (Last, First, Middle) Driver's License Other Form of PhotoIdentification with Signature Documentation of Parentage, Guardianship, Legal Custody OR Authority to Act on Behalf of Parent or Legal Guardian, as applicable Birth Certificate Consular Report of Birth Abroad Adoption Decree Current Custody/ Guardianship Court Order Evidence of Authority to Act on Behalf of Parent or Legal Custodian Other City State or Country Postal Code Work Phone Cell Phone Email Address Signature Please read the Dual Nationality for Children information accompanying this form. It relates to a child who may have a foreign nationality in additionto U.S. nationality. Please submit via e-mail, fax, or mail the completed form along with the proper copies of the original documents to the U.S. Department of State, Overseas Citizen Services, Children's Issues; Attention: Children's Passport Issuance Alert Program; SA-17, 9th Floor, Washington, DC 20522-1707; Email: PreventAbduction1@state.gov; Telephone Number 1-888-407-4747, Fax Number 202-485-6222. Passport (mm-dd-yyyy) Date I object to the Issuance of a U.S. Passport to the Aforementioned Child, but I understand that under prescribed circumstances the Department is authorized to issue the passport nonetheless. (s) (CRBA) (s) (es) (see 22 CFR 51.28) I request that the U.S. Department of State notify me if it receives a U.S. passport application for the above-mentioned child, or if an application is currently pending, or if there is any U.S. passport still valid for the child's travel. (mm-dd-yyyy) DUAL NATIONALITY FOR CHILDREN DS-3077 Page 2 of 2 PRIVACY ACT STATEMENT AUTHORITY: The information solicited on this form is requested pursuant to provisions in Titles 8 and 22 of the U.S. Code, as well as the corresponding federal regulations, including specifically 22 U.S.C. § 211a and Public Law 106-113, Div. B, §1000(a)(7) [Div. A., Title II, §236] of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001 and Executive Order 11295 (Aug.5, 1966), and the regulations contained in 22 C.F.R. § 51.28.PURPOSE: The primary purpose for soliciting the information is to enable the U.S. Department of State to notify you of any pending U.S. passport applications for the child identified on the form and of any U.S. passport held by the child that is still valid for travel. The child's social security number is requested because that number is a unique identifier used to establish the identity of the passport holder. ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies, to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement and administrative purposes. It may also be disclosed pursuant to court order. The information may be made available to foreign government agenciesto fulfill passport control and immigration duties. The information may also be provided to foreign government agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or otherwise address potential violations of law or to further the Secretary's responsibility for the protection of U.S. nationals abroad. This would include, among other entities and agencies, disclosure to The National Center for Missing and Exploited Children, Central Authorities of countries party to the Hague Convention on the Civil Aspects of International Child Abduction ("the Convention"), attorneys of record and legal aid services to assist in facilitating operations under the Convention; local police in connection with notification of next-of-kin and child custody disputes; social services agencies; and parents involved in cases brought under the Convention. The information may also be made available to private U.S. citizen 'wardens' designated by U.S. embassies and consulates. For a more detailed listing of the routine uses to which this information may be put, see the Prefatory Statement of Routine Uses and the listing of routine user set forth in the System of Records Notice (SORN) for Overseas Citizens Services Records (State-05)., found at: http://www.state.gov/m/a/ips/c25533.htmDISCLOSURE: Filing a request through the Children's Passport Issuance Alert Program and providing the information requested on this form, including the child's social security number, is voluntary. Failure to complete the form may result in a passport being issued to your child without your knowledge. Many children, born in the U.S. or born abroad to a U.S. citizen parent, are citizens of both the U.S. and another country. A child may acquire the citizenship of a foreign country, for example, through the child's birth abroad, or through a parent. There is no requirement that a U.S. citizen parent consent to a child's acquisition of another nationality. Even though U.S. law may prevent one parent from obtaining a U.S. passport for a child (for example, because of the two-parent signature requirement), a parent may still be able to obtain a foreign passport for a dual national child from the embassy or government of the other country. Under U.S. law, a United States citizen child is required to enter and depart the UnitedStates on his or her United States passport. However, please be advised that, since there are currently no exit controls from the United States, U.S. citizen children can still exit the United States undetected on foreign passports.U.S. law and regulations concerning the issuance of U.S. passports do not apply to foreign governments when they issue passports to people (including children) whom they consider to be citizens of their country, whether or not the foreign passport is issued in the United States and/or to a person the United States considers to be a U.S. citizen. If you think there is a possibility that your child may have another nationality, you are encouraged to contact the relevant country's embassy or consulate directly to inquire about the rules governing the issuance of that country's passport to your child, including the possible availability of mechanisms to prevent the issuance to your child of that country's passport without your consent. The address and telephone numbers for the embassies and consulates for foreign countries within the United States can be found on the Consular Affairs web page at >>travel.state.gov